Sharp Rise of C-Sections Defies Best Evidence and Best Practice




The U.S. c-section rate jumped to 29.1% in 2004. This record-setting preliminary figure from the Centers for Disease Control and Prevention represents a sharp increase of more than 40% over 8 years (Hamilton 2005).

Why is the c-section rate rising?

Many factors are driving cesarean rates up, including:
  • providers' fear of lawsuits: given the way our legal system works, even when scientific evidence supports vaginal birth, providers may feel that performing a cesarean reduces their risk of being sued or losing a lawsuit
  • forced cesareans: more and more women who have had a previous cesarean or whose babies are in a breech rather than head-first position are unable to find doctors and hospitals willing to offer vaginal birth due to fear of lawsuits
  • casual attitudes about surgery: our society is more tolerant than ever of surgical procedures, even when not medically needed
  • growing belief that c-section is "safe" and vaginal birth is "harmful": these opinions began to form before a careful look at the relevant research, and the research does not support them (see "What are the health costs...", below).
  • side effects of other common procedures: attempts to start labor artificially (labor induction) and use of electronic fetal monitoring to see how a baby responds to labor interventions are on the rise, and both increase the likelihood that a woman will have a c-section
  • failure to support normal physiologic labor: care that promotes normal vaginal birth processes - such as continuous labor support from a doula, or use of hand movements to turn a breech baby to a head-first position (external version) - greatly lowers the likelihood of c-section.
With more favorable conditions and more appropriate care, a very large proportion of c-sections that are performed in the U.S. could be avoided.


Why are healthy mothers and babies experiencing surgical birth when there is no medical reason?

Birth certificates are the primary source of national data on cesarean births. A recent analysis found that more and more U.S. women who have c-sections have no sign of any medical need for this surgery on their birth certificate (Declercq 2005).

What is driving these surgical procedures? Many policy, research and media reports assume that "elective" cesareans (with no medical rationale) are "maternal request" or "patient choice" cesareans. Because birth certificates and most other data sources provide no information about decision making processes and the motivation of participants, it is wrong and irresponsible to equate c-sections that had no apparent medical cause with "patient choice" cesareans.

One report that looked at this question found that most cesareans with no medical rationale were proposed by doctors, not mothers (Kalish 2004). When mothers ask for such surgery, it is important to understand their motivation, including whether they had access to balanced accurate information on harms and benefits of cesarean versus vaginal birth, access to choices and support for their choices. We need to better understand why women request a c-section with no medical reason, but this should not divert attention from physician and hospital led influences on escalating cesarean rates (Gamble 2000).

Many obstetricians have begun to support "patient choice" cesarean, but do not support women's right to choose vaginal birth after cesarean (VBAC), vaginal breech birth, and out-of-hospital birth, although the best research suggests that these would be reasonable choices for many women.

This selective support for women's right to choose surgical birth raises important questions about motivation and conflicts of interest. Cesareans may be attractive to providers who feel that the surgical procedures reduce their risk of being sued or help them better schedule and control their professional and personal lives. They may be attractive to hospitals due to increased revenue relative to vaginal birth (see "What are the financial implications...", below). An independent investigation is urgently needed to clarify whether these conflicts of interest are driving cesarean rates up and jeopardizing the health of mothers and babies.


What are the health costs of c-sections with little or no benefit?

To provide evidence-based guidance to women and other stakeholders, Childbirth Connection carried out the first and only systematic review to identify the full range of harms that may be worse with c-section or vaginal birth.

Many adverse effects did differ, and nearly all favored vaginal birth. Here is the main conclusion:
  • Unless there is a clear, compelling and well-supported justification for cesarean section or assisted vaginal birth, a spontaneous vaginal birth minimizing use of interventions that may be injurious to mothers and babies is the safest way for women to give birth and babies to be born.
For a full summary of review results, see the appendix to What Every Pregnant Woman Needs to Know About Cesarean Section. For a listing of all harms that favored vaginal or cesarean birth, see the cesarean booklet summary (PDF).

The following adverse effects were more likely with c-sections:
  • shorter term harms to mothers, such as infection, blood clots and stroke, emergency hysterectomy, surgical injury, more severe and longer lasting pain, poorer overall functioning
  • ongoing harms to mothers, such as pelvic pain and twisted, blocked bowels
  • harms for babies, including surgical injury, difficulty getting breastfeeding going, breathing problems at birth, asthma in childhood and adulthood
  • future reproductive harms for mothers, including infertility, ectopic pregnancy, and serious problems with placentas such as growing into the cesarean scar (placenta accreta) or separating too early from the uterus (placental abruption)
  • harms for babies in future pregnancies, including stillbirth or newborn death, low birthweight, physical malformation.
In addition to painful perineum, just two adverse effects were more likely in mothers with vaginal birth: leaking urine (urinary incontinence) and leaking gas or stool (bowel incontinence). Unfortunately, we can't make good sense of this research for 2 reasons:
  • effects of common, harmful, unnecessary obstetrical practices: incontinence problems may not be due to "vaginal birth" per se but could be the result of widely used practices such as cuts to enlarge the opening of the vagina (episiotomy), forceful staff-directed pushing and pushing while lying on the back
  • measurement problems, such as investigating too early during the recovery period and using very inclusive definitions that are not based on women's concerns.
As only about 3% of women who give birth vaginally have any degree of new urinary or bowel incontinence problem, respectively, a year after birth, it is essential to improve the quality of vaginal birth practice and help women resolve any problems by non-invasive measures (for example, "Kegel" pelvic floor muscle exercises) rather than tolerating major abdominal surgery for healthy mothers and babies.

In short, unnecessary c-sections pose plenty of risk to mothers and babies, and offer no clear benefit.

What are the financial implications of a runaway c-section rate?

There is another cesarean-related cost. On average, hospitals charge many thousands of dollars more for a c-section than for vaginal birth. And among the hundreds of procedures performed in U.S. hospitals, c-section is the most common one.

In 2003, U.S. hospitals charged an average of
  • $15,519 for a c-section with complications
  • $11,524 for a c-section with no complications
  • $8,177 for a vaginal birth with complications
  • $6,239 for a vaginal birth with no complications.
These figures from the U.S. Agency for Healthcare Research and Quality are displayed in a labor and birth charges graph (PDF).

The most common reason for hospitalization in the U.S. is a woman having a baby, and there are over 4 million births every year. Avoidable cesarean surgery adds billions of dollars to the burden of health care costs for governments, employers and individuals in the U.S. Access to health care coverage is jeopardized, and health care costs threaten the economic stability of governments, businesses and families. We cannot afford to tolerate costly, avoidable surgical procedures.

What is the ideal c-section rate?

As c-sections have troubling health and financial downsides, they should only be used when they offer a clear, established health benefit. Although needs vary from woman to woman, very low c-section rates are possible for the majority of mothers and babies who are healthy. Both the largest ever study of women giving birth in birth centers (Rooks 1989) and the largest ever study of women giving birth at home (Johnson 2005) found that just 4% of those who began labor in those settings had a c-section. Moreover, neither study found evidence that these low rates and this type of care posed extra risk for mothers and babies when compared to similar healthy mothers and babies experiencing hospital birth. However, as the Johnson report points out, 19% of low-risk mothers end up with c-sections in U.S. hospitals.

"Practice style" (and thus, the likelihood of using cesareans and other maternity interventions) can vary greatly from one maternity provider to another and one place of birth to another. The largest birth center and home birth studies underscore the value of careful choice of maternity caregiver and place of birth.

Variation in practice style also has major cost implications, as shown in the birth charges graph (PDF): in comparison with average hospital charges of $6,239 (plus charges for newborn care and anesthesiology services) for an uncomplicated vaginal birth, the average birth center charge was $1,624 (with no extra newborn or anesthesia charges) in 2003.


Our in-depth Maternity Topics provide more information on these and related issues: See also




References

Declercq E, Menacker F, MacDorman M. Rise in "no indicated risk" primary caesareans in the United States, 1991-2001: Cross-sectional analysis. BMJ 2005;330:71-2.

Gamble JA, Creedy DK. Women's request for a cesarean section: a critique of the literature. Birth 2000;27:256-63.

Hamilton BE, Ventura SJ, Martin JA, Sutton PD. Preliminary births for 2004: infant and maternal health. Health E-stats. Released November 15, 2005.

Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416.

Kalish, R.B., McCullough, L, Gupta, M., Thaler, H.T., & Chervenak, F.A. (2004). Intrapartum elective cesarean delivery: A previously unrecognized clinical entity. Obstet Gynecol, 103, 1137-1141.

Rooks JP, Weatherby NL, Ernst EK, Stapleton S, Rosen E, Rosenfield A. Outcomes of care in birth centers: The National Birth Center Study. N Engl J Med 1989 321:1804-11.

U.S. Agency for Healthcare Research and Quality. HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: AHRQ, 2005. [DRGs 370-373.]

Most recent page update: 6/30/2008


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